Mock Exam Board Review 2022 See all questions (Q) AAABBB © Time left: 00:59:47 Question 1 of 100 42 years old hospital employee was referred because of BP 148/90 mmHg found in his annual checkup. His mother died with heart disease and no other member has high BP. He never ‘smoked and has no Diabetes. His BP at home by automated machine is 110 -130/80 mmHg. His creatinine and urine analysis were normal but his fasting Cholesterol ang LDL were elevated You strongly advised him for healthy diet, low salt and weight loss which he followed, however in his subsequent visit his BP stil high which was confirmed by ambulatory BP monitoring. What should you do now? A. Start Amiodipine 5 mg {day B. No agent preference @ . Start Enalapril 5 mg Bid D. Start with thiazide 25 mg /dayQuestion 2 of 100 A 47-year-old builder presented with paranesthesia in both hands which was worse at night. His hands felt swollen, although they were not painful, and he had needed to buy a larger pair of work gloves. When at work he found that his hands fell weak. Over the past six months he had been experiencing urinary frequency, fatigue and increased thirst. He had a past medical history of obesity and hypertension and his brother had type Il diabetes mellitus. His only ‘medication was ramipril. He was a heavy smoker with a 20 pack year history. ‘On examination of the arms there was weakness of thumb abduction bilaterally and diminished ‘sensation over the radial three and a half digits, Percussion over the palmar aspect of the wrist reproduced the paranesthesia he described on presentation, On examination of the chest and ‘abdomen there were areas of pigmentation in both axil @ protuberant abdomen and an elevated body mass index (BMI). land striae over the abdomen. He had Which of the following investigations is most likely to be diagnostic? ALEMG B. MRI of the pituitary and visual fleld testing ‘C. GH measurement and Dexamethasone suppression test D. Oral Glucose tolerance test with serum glucose, IGF-1 and GH @ measurements E. Fasting Glucose on three occasions, HBAtc and 9 am Cortisol measurementQuestion 3 of 100 Which of the following agents are shown to Improve survival in heart failure with reduced ejection fraction (HFEF)? A. Enalapril B. Hydrochlorothiazide ©. Digoxin D. Metoprotol tartrate E. Milrinone Question 4 of 100 Alllof the following are characteristic extra-articular manifestations of rheumatoid arthritis, EXCEPT: A. Anemia B. Cutaneous vasculitis ©. Pericarditis, D. Secondary Sjagren syndrome E. ThrombocytopeniaQuestion 5 of 100 Which of the following Hemoglobin electrophoresis represents HbS/B+ thalassemia? A. HbS=50% , HbF « 5% , HbC=50 B. HDS > 90% , HDF < 10%, HBAZ < 3.5% . HbS > 60%, HDF <20%, HBA2 > 3.57%, HBA=10-30% e D. HbS < 70% | HBF > 30% . HbA2 <2.5% E. HbS > 80% HDF < 20% HbA2 > 3.5% Question 6 of 100 A.30-year-old man is evaluated for arthritis. Three weeks ago he noticed the abrupt onset of dysuria without a discharge. Two weeks later, he developed the acute onset of warmth, pain, ‘and swelling in the left knee. Two days later, pain and swelling developed over the left heel. He also noted the onset of stinging and redness of the right eye. He takes no medications. The ysuria and eye symptoms have since resolved. On physical examination, vital signs are normal. A moderate effusion of the left knee is present with warmth and pain with range of motion. Diffuse swelling, warmth, erythema, and tenderness are present at the insertion of the left Achilles tendon at the calcaneus, There is no rash. Radiographs of the left knee show a joint effusion, no bony abnormalities, and normal joint space. Aspiration of the left knee is perfarmed; synovial fluid analysis shows a leukacyte count of ‘5000/uL (5.0 * 109/L) with 65% neutrophils and 35% mononuclear cells, negative Gram stain and cultures, and no crystals. Which of the following is the most appropriate diagnostic test to perform noxt? A. Chlamydia nucleic acid amplification urine testing ° B. C-reactive protein c. HLA.B27 D. interferon-gamma release assayQuestion 7 of 100 ‘A 82-year-old woman presents for evaluation of palpitations. She notes the intermittent ‘sensation of her heart “flip-lopping” in her chest for the past month. Review of systems is notable for fatigue and subjectively decreased energy. ‘On physical examination, she is well appearing. The jugular venous pressure is 6 cm of water. There is a parasternal ft and a grade 2/6 mid peaking systolic murmur atthe left upper sternal border. The second heart sound is widely spit without respiratory variation, and pulmonic ‘component of the second heart sound is prominent. The extremities are warm without edema. Is shown: An olectrocardiogram © A.wott-Parkinsor-wnite syndrome © B. Anythmogenie right ventricular cardiomyopathy ® C. Atrial septal defect @ © deta stenosisQuestion 8 of 100 A 19-year-old woman is evaluated in the emergency department for a 2-day history of fever, headaches, and jaundice, She vacationed in Hawaii 1 month ago and reports swimming in lakes and rivers. She was diagnosed with a flu-like ines 2 weeks ago that resolved spontaneously. She reports no history of a rash. She is sexually active with one partner. She takes no medications other than an oral contraceptive. ‘On physical examination, she is alert and oriented, Temperature is 38.9 °C (102 °F), blood pressure is 92/60 mm Ha, pulse rate is 124/min, and respiration rate is 24/min. Generalized lymphadenopathy, conjunctival suffusion, and scleral icterus are noted. She has photophobia, and passive neck flexion elicits resistance and discomfort. The remainder of the examination is unremarkable. Labs: Blood and chemistry ‘lirubin total 5.6 mg/dl (95.8 umoy/) 0.3.1.2 mg/dl (51-205 umel/) Creatinine 2.3 mg/el (203 umol/) 0.7-1.3 ma/dl(61.9-115 umol/) se wac 152 /ul (Neut 80%) o5/ul Glucose 72 mg/l (2.0 mma} 0-80 mg/al (22-44 mmol Protein 7 mg/dl (760 me) 15-60 mg/l (150-600 mg/l) TSF Gram stain Negative SF culture Pending Which of the following is the most likely cause of the patient's findings? [A. Herpes simplex virus infection B. Neurosyphils ©. Leptospirosis e D. Acute retroviral syndromeQuestion 9 of 100 A 58-year-old Caucasian man with a background of type 2 diabetes mellitus presents to the GP. with worsening pedal oedema. On further questioning, he reports having previously had weight loss and alteration in his bowel habit over the past six months. On examination, he is unkempt, and there is pitting oedema to both thighs and sacral oedema, Lungs are clear, the cardiac examination is unremarkable and the JVP is not elevated. Abdominal exam is unremarkable, as js a digital rectal examination. Urine dip shows protein +++ but is otherwise negative Hb 7ef [Na 135 mmol/i_| Bil 20 umol/i Platelets | 340* 1071 | K 3.7mmol/l_| ALP aul ‘WaC 12° 10°71 | Urea émmoi/l_| ALT 80.u/l Neut 371071 [Creatinine | 67umol/_| GGT 30u/l Lymph 7710/1 = oem] MO azfl | Albumin 18e/l What is the likely diagnosis? ‘A. Congestive cardiac failure B. Memberonus gloumerlonephritis secondary to colorectal cancer . Diabetic Kidney disease D. Hypoalbuminemia secondly to poor nutritional E. Alcoholic CirrhosisQuestion 10 of 100 ‘A.60-year-old woman with past medical history of hypertension and COPD is brought to the ‘emergency room by her daughter. She is lethargic and is having difficulty walking. She has noted Increasing difficulty breathing over the past few hours. Physical examination is notable for temperature of 100.7°F (38.5 C), blood pressure of 150/70 mm Ha, respiratory rate of 24 breaths por minute, and O2sat 88% on room air. She has difficulty with finger-to-nose and rapid alternating movements. She has fine crackles bilaterally. A complete blood count is notable for ‘2 white blood cell count of 110 x 106, hemoglobin of 8, and platelets of 75,000/L. A chest X- ray shows bilateral infiltrates. What would be the appropriate next step in management of this patient? A. Give a unit of PR8Cs. B. Start antibiotics for possible pneumonia and follow for symptom improvement before initiating more invasive procedures. . Start steroids and antibiotics for COPD flare D. Start leukapheresis while establishing diagnosis ° E. Establish diagnosis and start appropriate therapyQuestion 11 of 100 A 23-year-old man is evaluated for a furuncle on the left forearm that appeared 1 day ago. Medical history is notable only for anaphylaxis with administration of trimethoprim- sulfamethoxazole, Ho is otherwise well and takes no medications. (On physical examination, temperature is 38.3 °C (100.9 °F), blood pressure is 124/75 mm Hg, pulse rate is 110/min, and respiration rate Is 15/min, A 2- x 2-cm fluctuant lesion is present on the right forearm with 1 cm of surrounding erythema. The remainder of the examination is, unremarkable, ‘After incision and drainage of the abscess, a culture is obtained. Which of the following is the most appropriate additional treatment? A. Clinical follow-up B. Oral doxycycline Qe ©. Oral peniciin D. Oral cephalexin Question 12 of 100 Which of the following arrhythmias is unusual in digoxin toxicity? ‘A. Non-paroxysmal arial tachycardia with varying block: B. Wenkebach phenomenon ©. First-degree heart block D. Bidirectional ventricular tachycardia E. Type-tI second-degree heart block QoQuestion 13 of 100 In the following group of patients with asymptomatic chronic severe aortic regurgitation Which one has a class indication for aortic valve replacement? ‘A. ASB.year-old man with resting eft ventricular ejection fraction (LVEF) of — @ 45% B. A66-year-old man with resting LVEF of 65% and LV end-diastolic dimension of 7.0 cm C. A59-year-old woman with resting LVEF of 65% and LV end-systolic dimension of 5.5 om D. None of the above E. A59.year-old woman with resting LVEF of 55% , LV end-diastolic dimension of 6.6 cm and LV endsystolic dimension of 5.0 cm Question 14 of 100 A.58-year-old man is admitted to the hospital with solid food dysphagia for several months, which has progressed to the point that he can no longer swallow liquids. Within seconds of swallowing liquids, he regurgitates the liquid back up and spits it into @ cup. He has not been. able to eat solid or soft foods for weeks, and has had limited oral intake of fluids over the last 4 days. On exam, he is orthostatic and has dry mucous membranes. He has no palpable lymphadenopathy or hepatomegaly. Computed tomography of his chest and abdomen reveals thickening of his distal esophagus, concerning for esophageal cancer. An upper endoscopy for tissue sampling and stenting is planned in 2 days. In the interim, parenteral nutrition is started. ‘The next day, the patient had new onset dyspnea and expired. Which of the following is the most likely laboratory abnormality leading to this outcome? A. Hypomagnesemia B. Hyperkalemia . Hypophosphatemia Qe D. Hypercalcemia E. HypoglycemiaQuestion 15 of 100 A72.year-old woman with a history of hypertension presents to you for a second opinion. She hhas had six months of diarrhea, abdominal discomfort, bloating and weight loss. Her prior workup included normal labs, including a TTG IgA and IgA while eating gluten, stool studies that were negative for infection and an EGD with duodenal biopsies showed villous atrophy. ‘She is currently on a gluten free diet with no improvement. What is the best next step in evaluation? ‘A. Abdominal/pelvis CT scan B. Colonoscopy with random biopsies . Start loperamide D. Reviow her medications Qe Question 16 of 100 A.17 years old female developed acute stroke secondary to sickle cell and after a prolong stay in ICU, fortunately she makes a full neurologic recovery from her acute stroke/infarct. She follows up with her Hematologist. Which of the following should be recommended at this time? A. High dose folic acid (5 mg dally) B. Monthly monitoring of HDS; initiate exchange transfusion if HbS < 50% . Chronic transfusions Qe D. Observation E. Erythropoietin to keep Hb >10 g/dlQuestion 17 of 100 ‘A 36-year-old female presents with severe diarthea for the past several months. She has undergone @ colonoscopy, blood tests, and stool testing, and all studies have been normal. She ‘adrmits to drinking well water for several years. On examination, she also has linear white lines (on her fingernails. Based on this physical finding and her symptoms, which of the following is, the most likely cause of her diarrhea? ‘A. Arsenic poisoning ° 8. Giardia that has not been detected . Carbon monoxide poisoning D. Marijuana abuse E. Cocaine abuse Question 18 of 100 42-year-old woman is evaluated for fatigue with facial and lower-extremily edema of 6 weeks’ uration. She has no history of diabetes mellitus, cigarette smoking, or illicit drug use. On physical examination, blood pressure is 145/55 mmHg. Cardiac and pulmonary examinations are normal. There is periorbital edema. The abdomen is soft and without masses. There is 2+ lower-oxtremity edema, 24-Hour urinary protein excretion showed 8 gm of protein. Wich ofthe following isthe mast ikelysiagnosts? A. Focal segmental glomerulosclerosis e B. Membranoproliferaive GN 6. Minimal change glomerulopathy D. Membranous nephropathyQuestion 19 of 100 A 79-year-old man with coronary artery disease managed with a prior cardiac stent placed several years ago who takes dally aspirin monotherapy is admitted to the ICU with melena and 2 significant hemoglobin drop, ‘An upper endoscopy reveals an antral ulcer with a pigmented spot prompting the placement of three hemoclips. H. pylori testing is negative. Which ofthe following isthe best strategy for his medical management afterdischarge? ‘A. Twice dally PPI and hold his aspirin for one week. Qe B. Twice dally PP and immediate resumption of aspirin CC. Change his aspirin to clopidogrel D. Twice daily PPI and hold his aspirin until ulcer healing is confirmed A 46-year-old man has had hypertension, diabetes mellitus for 20 years, gout for 10 years and recently found to have chronic kidney disease. Ten years ago, he had his first attack of gout Over the next few years, he had multiple attacks of gout and visible tophi developed on his, elbows. Two years ago, when his serum creatinine level was 190 (44-115 pmol/L), he was prescribed allopurinol 100 mg. This treatment led to a drop in his serum urate level from 650 to 530 (200-410 jumolL). One year ago, the dose of allopurinol was increased to 300 mg and colchicine 0.6 mg every other day was added. He is using insulin, hydrochlorothiazide 12. mgiday, losartan 25 mg and aspirin 81 mg daily. He has not had a gout flare in the past 9 ‘months but the tophi remain unchanged. His BP is 150/90 mmHg, creatinine level is 230 mol/L and serum urate is 410 umolL Which of the following interventions is most appropriate at this time? A. Add probenecid B. Switch losartan to Lisinopril ©. Discontinue the ASA D. Discontinue allopurinol and start Feboxostat Qo E. Discontinue colchicineQuestion 21 of 100 Which of the following tests Is best avoided in investigating a 32 year-old-night shift nurse who presents with facial plethora, obesity, new onset hypertension and impaired fasting glucose? A. Aldosteroneirenin ratio B. Micnight salivary cortisol Qe ©. Hemoglobin Ate D. 1 mg dexamethasone suppression test E. 24-hour urinary free cortisol Question 22 of 100 A 62-year-old female with a history of coronary artery disease has just been admitted to the ICU with a left-sided spontaneous basal ganglia hemorrhage. The patient takes 325 mg of aspirin dally at home, and you are considering platelet transfusion. Which of the following has been demonstrated regarding platelet transfusion in this setting? A. Improved chances of survival at 3 months B. Improved chances of survival to hospital discharge, ©. Associated with poorer outcomes at 3 months Qe D. Decreased hospital length-of-stayQuestion 23 of 100 ‘A.34-year-old woman has a three-year history of SLE, characterized by pleurisy, arthritis, photosensitivity, and oral ulcers. Laboratory studies have revealed stable leukopenia and a positive ANA, ‘She has taken hydroxychloroquine, 200 mg daily, for more than a year. She also has received two courses of corticosteroids; the last course was administered six months ago for treatment of pleurisy. She presents today with a three-week history of lower extremity dependent edema and progressive lethargy. On physical examination, vital signs are normal. No rash or oral ulcerations are noted. The heart and lungs are normal. Minimal swelling and tenderness is present in the small joints of the hands. There is bilateral pitting edema to mid-calf. (See lab results) Test Results Normal value Hemoglobin 330 120-160 g/t wac 28 45 405x107 Platelet count 140 150 -400% 107. ESR 5 3-15 mmr Creatinine, serum 120 44-115 mol/L APT 40 30-40 g/t C3 oF OBS et cHSO 3% E. GH stain Question 39 of 100 Which of the following therapies are indicated in asymptomatic HCM patients with no ‘outflow obstruction? A. None of the above Qe B. Amiodarone to reduce risk of sudden death . Bota blocker to reduce atrial fibilation isk D. All ofthe above E. Calcium channel blocker to improve cardiac performanceQuestion 40 of 100 ‘A50 years old man presents to the ER with § days history of productive cough and fever. He is. ‘SOB and is hypoxic 88% on RA. His 02 levels improve with O2, 2 Limin to 96%. His chest X- ray shows a new consolidation in the right lower labe and he was admitted as a case of pneumonia. Later on, the patient developed ARDS with significant desaturation requiring mechanical ventilation with high Fio2 requirements. What is the cause of hypoxia? A. Shunt Qe fusion abnormality ©. VIQ mismatch D. Hypoventilation Question 41 of 100 ‘Two months after delivering hor first child, a 27-year-old woman started experiencing progressive and sever headaches. She also noticed profound fatigue, weight loss and lack of appetite. She reported waking up several times at night to pass urine, and feels the need to keep body hydrated all the time. Pituitary MRI showed a uniform enhancing sellar lesion measuring 2 cm with thickened pituitary stalk. Which of the following statements is correct? A. She is likely o have a normal ACTH stimulation test B. Her primary treatment will be a course of steroids e . Sho willneed an urgent surgery to decompress the sellar area D. Ifa pituitary biopsy was obtained, twill show necrotic tissue E. Octreatide therapy will reverse the underlying pracessQuestion 42 of 100 A 68-year-old woman with known seafood allergy ordered soup without knowing the stock was ‘made with shellfish. Within 10 minutes, started to have diffuse hives and then started vomiting. What is the next best step? ‘A. Intramuscular injection dose of epinephrine Qo B. Oral dose of diphenhydramine ©. Oral dose of diphenhydramine and IM dose of epinephrine D. Oral steroids E. Watch and waitQuestion 43 of 100 Which one of the following approaches is most appropriate for treating hyperglycemia in a 52- year-old woman who recently started taking immediate-release metformin 1000 mg twice dally for newly diagnosed type 2 diabetes but discontinued the medication because of diarthea and flatulence? A. Restart metformin at the same dose (1000 mg twice daily), and add loperamide 2 mg twice daily B. Restart immediate-release metformin but ata lower dose (500mg once @ daily) . Start extended-release metformin 2000 mg once daily D. Start extended-release glipizide 10 mg once daily Question 44 of 100 Patient was admitted to the hospital with confirmed diagnosis of MERS-CoV. What is the most appropriate isolation precaution? A. Contact isolation B. No isolation is required . Droplet isolation D. Contact and airborne isolation E. Contact and droplet isolation QeQuestion 45 of 100 You are asked to evaluate a 27-year-old internal medicine resident reporting 1 week of cough, coryza, and a low-grade fever. Today, he has developed rapidly escalating chest discomfort while in clinic. He notes that the pain becomes more intense when he takes a deep breath. You perform a standard 12-lead ECG. On examination, his blood pressure is normal, he is afebrile, and his jugular venous pulse is not elevated. However, he appears mildly uncomfortable from the chest pain The next most appropriate step would be which of the following? A. Administer aspirin, intravenous heparin, sublingual nitroglycerin, and. clopidogrel B. Emergently obtain transthoracic echocai pericardiocentesis. gram with possible ©. Emergently perform coronary angiography to evaluate for acute myocardial infarction, D. Prescribe ibuprofen and colchicine Qo E. Refer for treadmill stress testQuestion 46 of 100 A 54-year-old woman with dyspepsia undergoes UBT, which demonstrates H. pylori infection Which of the following statements about first-line anti ic therapy for H. pylori is true? A. Tho eradication rate of traditional triple therapy consisting of a PP Q clarithromycin, and amoxicilin for 10 days is less than 70% in Saudi Arabia B. Sequential therapy is superior to traditional triple therapy in Saudi Arabia. €. Preceding courses of macrolide antibiotic decrease the likelihood of having clarithromycin resistant strain of H. pylori D. Triple therapy with a PPI, clarithromycin, and amoxicilin yield similar eradication rates when treating for 7 days as for 14 days. Question 47 of 100 In the following group of patients with asymptomatic chronic severe aortic regurgitation, which cone has a class | indication for aortic valve replacement? A. A66-year-old man with resting LVEF of 55% and LV end-diastolic dimension. of 7.0 cm. B. None of the above ©. 59-year-old woman with resting LVEF of 65% , LV end-diastolic dimension of 6.6 em and LV end-systolic dimension of 5.0 cm D. A59-year-old woman with resting LVEF of 65% and LV end-systolic dimension of 5.5 om E. A58-year-old man with resting left ventricular ejection fraction (LVEF) of § @ 45%Question 48 of 100 A 46-year-old man presented with 2 2-week history of weakness and severe pain in his right thigh, hip, and buttocks. The pain started fairly suddenly and progressed to the point wher needed a cane to walk. On examination, he had mild atrophy of the muscles in this area, he Which of the following laboratory tests is most likely to be abnormal in this patient? ‘A. Thyroid-stimulating hormone B. Hemoglobin Atc QO ©. Moming cortisol D. Angiotensin-converting enzyme Question 49 of 100 Which of the following is a risk factor for Obstructive Sleep Apnea? A. BMI < 30 B. Female gender ©. Post:menopausal women Qe D. Young age. Which of the following vaccines is NOT contraindicated in pregnancy? A. Zoster vaccine B. MMR . Hepatitis B virus D. Oral polio virus E. Human papilloma virus QeQuestion 51 of 100 A 47-year-old female with a history of metastatic breast cancer presents to the emergency department with headache and altered mental status. The patient is admitted to the hospital. and an MRI demonstrates evidence of scattered leptomeningeal enhancement. A lumbar puncture is performed. Which of the following CSF findings does not support a diagnosis of carcinomatous meningitis? A. Protein of 18 mg/dl. Qe B. Glucose of 30 mg/l. ©. Leukocyte count of 75/mm3 D. Opening pressure of 30 cm H20 Question 52 of 100 ‘Switching to Sacubitril Valsartan in place of an ACE inhibitor or ARB would be most ‘appropriate for which of the following heart failure patients? ‘A. 62-year-old woman with ischemic cardiomyopathy, LVEF 40%, NYHA I| symptoms who developed angioedema previously on an ACE inhibitor. B. 76-year-old woman with heart failure and preserved ejection traction (HFDEF), NYHA Il symptoms, taking metoprolol, Valsartan, and furosemide C. 72-year-old man hospitalized for heart failure decompensation, LVEF 35% land severe (NYHA IV) symptoms despite ACE inhibitor, beta-blocker and spironolactone D. 64-year-old man with non-ischemic cardiomyopathy. LVEF 98%, NYHA @ symptoms, comes for routine ofice visit on furosemide and optimal doses of metoprolol succinate and lisinoprilQuestion 53 of 100 A2T years old man is referred to you for evaluation of an abnormal chest radiograph. 5 months ‘ago, he consulted a doctor because of excessive thirst. He was eventually diagnosed with diabetes insipidus, which responded to desmopressin. He complains now of shortness of breath. He is a smoker with 28 pack years smoking history. His images are shown. = = x ~ What is the most likely diagnosis? AL IPF B. Langerhan’s cell histocytosis Qo ©. Sarcoidosis D. Metastatic tumor of unknown primary site.Question 54 of 100 A 65-year-old man is evaluated for progressive dyspnea on exertion thal has occurred over the course of the past 3 months. His medical history is significant for an episode of necrotizing pancreatitis that resulted in multiorgan failure and acute respiratory distress syndrome. He required mechanical ventilation for 6 weeks prior to his recovery. He also has a history of 30, pack-years of tobacco, quitting 15 years previously. He is not known to have chronic obstructive pulmonary disease. On physical examination, a low-pitched inspiratory and expiratory wheeze is heard, loudest over the mid-chest area. On pulmonary function testing, the forced expiratory volume in 1 second (FEV) is 2.5 L (78% predicted), forced vital capacity {FVC) is 4.00 L (94% predicted), and FEVIUFVC ratio is 62.5%. The flow-volume curve is shown in Expiratory TLC w RV Volume Inspiratory Flow A. Aspirated foreign body B. Chronic obstructive pulmonary disease ©. Idiopathic pulmonary fibrosis D. Subglotic stenosis Qe E. Unilateral vocal cord paralysisQuestion 55 of 100 70-year-old female known case of hypertension on hydrochiorothiazide, brought to the hospital by her family after an episode of seizure. Upon her arrival to ER: she was intubated and mechanically ventilated Her labs showed Na of 103 mEq/L (136-145 mEq/L), her weight is 80 kg. What the best next step in the management? A. Start hypertonic saline at rato of 200 ce/hr Qe B. Start hypertonic saline at rate of 50 ce/hr C. Start normal saline at rate of 150 ce/hr D. Discontinue hydrochlorothiazide and restrict fluid intake to less than 600 cclday Question 56 of 100 34-year-old woman is referred to you for 2 preoperative evaluation from an otolaryngology colleague who diagnosed a medullary thyroid carcinoma. The evaluation was prompted by a call from one of the patient's sisters who recently received the same diagnosis. The patient has, ‘no complaint, no past medical problems and she take no medications. Her vital signs are normal Upon examination, a 1.5 om right thyroid lobe nodule was felt without cervical lymphadenopathy. The rest of examination findings are unremarkable. Which of the following should you do preoperatively? ‘A. Measure levels of serum calcium and plasma fractionated metanephrine = @ B. Obtain genetic testing for RET proto-oncogene mutation . Request MRI of the abdomen D. Recommend proc normal ding with surgery ifthe patient's blood pressure isQuestion 57 of 100 the best candidate for a DXA scan? Which of the following indi |. 69-year-old heathy woman with essential hypertension taking @ B. 60-year-old healthy man with a normal TSH taking levothyroxine C. 55-year-old healthy man who fractured his humerus in a biking accident D. 26-year-old healthy woman whose grandmother has a hump (thoracic kyphosis) E. 50-year-old healthy, perimenopausal woman Question 58 of 100 A27-year-old G1PO at 34 weeks gestation presents to emergency department complaining of 2 2-day history of nausea and emesis. On physical examination, you notice that she is icteric sclera and skin, Her vital signs indicate a tenperature of 37.2°C (99°F), pulse of 102 beats per minute, and blood pressure of 130/84 mm Hg. Blood is drawn and the following results are obtained: WBC = 22,000, Het = 40.0, platelets = 72,000, SGOT/PT = 334/386, glucose = 58, creatinine = 180, fibrinogen = 1.9, PT/PTT = 16/50 ', serum ammonia level = 65 mmol/L (nl = 11-35). Urinalysis is positive for 3+ protein and large ketones. Which ofthe following isthe recommended treatment for this patient? A. Immediate delivery ° B. Cholecystectomy . Intravenous diphenhydramine D. MgS0é therapy E. Bed rest and supportive measures since this condition is selQuestion 59 of 100 A 74-year-old woman is evaluated in the emergency department for decreased responsiveness. ‘She has become progressively confused and lethargic. She lives alone and stopped taking her ‘medications at some time unknown. She was brought to the emergency department by @ family member. ‘The patient had a near-total thyroidectomy for multinodular goiter 3 years ago. ‘On physical examination, temperature is 36.1 °C (97.0 *F), blood pressure is 80/45 mm Hg, pulse rate is 46/min, respiration rate is 10/min, and oxygen saturation is 92% breathing ambient ait, BMI is 28. The patient is arousable with painful stimuli. She has a well-healed anterior neck ‘scar. The patient's skin is cool and dry. She has periorbital edema and bipedal edema. Other than bradycardia, the cardiac examination is normal. The relaxation phase of her deep tendon reflexes is delayed. Laboratory results show a sodium level of 129 mEqil. (129 mmol/L). Intravenous fluids are initiated. Which of the following is the I step in the management of this patient? A. A) Administer intravenous hydrocortisone. Qo B. 8) Administer intravenous levothyroxine and liothyronine ©. C) Administer norepinephrine D. D) Administer oral lovothyroxine Question 60 of 100 59-year-old postmenopausal woman presents for management of uncontrolled type 2 DM. She takes metformin monotherapy but has a HbA‘C of 8%. She also takes citalopram for Gepression and omeprazole for GERD. Her mother has osteoporosis, and she herself had evidence of osteopenia on a recent bone mineral density scan; her lowest T score was -2.9 at femoral neck. She has net had any fracture in adulthood, Which one of the following medications should be avoided when treating the patient's hyperglycemia? A. Pioglitazone Qo B. Sitagliptin ©. Exenatide D. LiraglutideQuestion 61 of 100 A23-year-old man experienced a grand mal seizure and had a large witnessed aspiration of, ‘gastric material. He is now on assist-control ventilation. His ventilator settings are as follows: Fraction of inspired oxygen (F102) 1.0; positive end-expiratory airway pressure (PEEP) §; tidal volume (VT) 6 mL/kg; ABG pH 7.2/PaCo2 57/Pa02 48; Pplat 29; adequate expiratory time, What, if anything, should be done? [A Increase PEEP, reduce VT, and increase rate e B. Increase PEEP ©. Reduce VT and increase rate D. Change the vent to HFOV E. Increase VT Question 62 of 100 ‘60-year-old woman is evaluated for her COPD. She has dyspnea and wheezing when walking on ground level. She is ex-smoker, She had one exacerbation 2 years ago that didn't require hospitalization (On physical examination, vital signs are normal; oxygen saturation is 95% on ambient air Lungs examination shows scattered wheezing. Cardiovascular examination is unremarkable. ‘Spirometry shows a post bronchodilator FEV1 of 60% of predicted and an FEVFVC ratio of 0.65, Electrocardiogram and chest radiography are normal. Choose the appropriate treatment and the stage of COPD for this patient? A. GOLD 2, Category A and start Long acting muscarinic antagonist B. GOLD 1, Category A and start short acting inhaled bronchodilator on PRN basis ©. GOLD 2, Category B and start Long acting muscarinic antagonist Qe D. GOLD 2, Category B and start short acting inhaled bronchodilator on PRN basisQuestion 63 of 100 45 years old lady with a lang history of mild asthma presents with cough, SOB and fever for 2 wooks. O/E chest is clear, CXR is shown, Labs show elevated eosinophil count, ESR 65, mild elevation IGE and weakly positive asperaillus preciptins. ‘The most likely diagnosis is: ‘A. Chronic eesinephilic pneumonia e B. Churg-Strauss syndrome C. Hypereosinophillic syndrome D. ABPAQuestion 64 of 100 You are called to evaluate a 22-year-old G1P1, who delivered an infant male at 36 weeks after an induction for preectampsia with severe feature. During her labor she required hydralazine to control her blood pressures. She is on magnesium sulfate for seizure prophylaxis. Her vital signs are: blood pressure 120/78 mm Hg, pulse 73 beats per minute, respiratory rate 10 breaths per minute, and temperature 37.3°C. She has adequate urine output at greater than 40 coh. On examination, she is somnolent and her speech is slurred. She is moving her extremities with no focality and deep tendon reflexes are absent. Which ofthe following isthe most likely cause of her symptoms? ‘A. Magnesium toxicity ° B. Adverse reaction to hydralazine C. Hypertensive stroke D. Sinus venous thrombosis, A 16-year-old female with sickle cell disease is admitted to the hospital for an acute stroke. Her baseline HigS is 85%, She is set up emergently for an exchange transfusion. What should the Hemoglobin $ level be less than to help prevent progression of cerebral Ischemia? A Hs < 40% B. HES < 50% Cc. Hbs < 30% e D. HBS < 20% E. HbS < 10%Question 66 of 100 Which of the following is TRUE about treatment of Tuberculosi A. All of the above B. Antboto choice or duration should be altered In the presence of drug @ . Treatment should be initiated after the results of antibiotics sensitivity test are available D. Antibiotics resistant is found only in patients with history of non-compliance E. Pregnant women should not be started on Isoniazid Question 67 of 100 21-year-old male college student is evaluated for profound fatigue that has been present for several years but has recently become debilitating. He also reports several foot spasms and cramps and occasionally sustained muscle contractions that are uncontrollable. He is otherwise healthy, takes no medications, and denies tobacco or alechol use. On examination, he is well eveloped with normal vital signs including blood pressure. The remainder of the examination is normal. Laboratory evaluation shows a sodium of 138 mEq/L, potassium of 2.8 mEq/L, chloride of 90 mEq/L, and bicarbonate of 30 mmol/L. Magnesium level is normal. Urine screen {for diuretics is negative, and urine chloride is elevated, Which of the following is the most likely diagnosis? A. Bulimia nervosa tic abuse €. Gitelman syndrome Qe D. Liddle syndrome E. Type 1 pseudohypoaldosteronismQuestion 68 of 100 A 34-year-old asthmatic female comes to the emergency room with progressive dyspnoea and non-productive cough over the past 3 days. Her best recorded peak expiratory flow is 60% of her personal best and she has an oxygen saturation of 90%. She has stopped taking inhaled corticosteroids because she is 27 weeks pregnant and does not feel comfortable receiving medication while she is pregnant. ‘She has been having mild symptoms for weeks. Now the symptoms have been getting worse and she has been waking at night for the past 10 days. She feels breathless and although she hhas used her rellaf inhaler every day in the past week and 3 times in the last hour, she does nat feel better. Which one of the following is the most appropriate initial treatment for this patient? ‘A. Oral and inhaled corticosteroids and oxygen supplementation B. High dose inhaled corticosteroids and inhaled short acting 8 agonists C. Oxygen supplementation, high dose inhaled corticosteroids and short acting B agonists D. Oxygen supplementation, systemic corticosteroids and short acting B Qo agonists Question 69 of 100 A 37-year-old female presents to the emergency department with approximately 2 weeks of progressively worsening clumsiness and drastic mood swings. Hor past medical history is significant only for Crohn's disease, for which she takes both natalizumab and infliximab. A contrast-enhanced GT scan of her head is performed, revealing hypodense, non-enhancing lesions in the cortical white matter of the frontal and parietal lobes. Despite treatment, the patient expires 1 month later. Which of the following is true regarding the most likely diagnosis? A. tis @ prion-based disease B. The diagnosis may be confirmed via CSF analysis, Qo ©. The pathologic process spares oligodendrocytes, D. The condition is universally fatal despite treatmentQuestion 70 of 100 ‘You evaluate an independent 84-year-old woman who has had 3 falls in the past year. She has not sustained serious injury, but her family is worried about her ability to live alone, The patient slates she simply slipped, and denies dizziness, chest pain, shoriness of breath, palpitations, cr other symptoms. Her only medical problems are osteoarthritis and a remote history of peptic. ulcer disease. She takes acetaminophen 2-3 times a week. Her vision is good, ‘She does not drink alcohol and is a lifelong nonsmoker. The remainder of the history is negative, Which of the following would be most helpful in evaluating this patient’ falls? risk of future A. Romberg test B. Lower extremity elevtromyetography ©. “Get up and go" test Qe D. Holter monitoring E. Head CT to evaluate for small vessel diseaseQuestion 71 of 100 A 64-year-old woman is hospitalized for progressive fatigue, dyspnea, orthopnea, and peripheral edema that have been present for the last 18 months. During this time, she has been hospitalized several times for heart failure with preserved ejection fraction. Her medical history is otherwise notable for hypertension. Her current medications are spironolactone, furosemide, and amlodipine. ‘On physical examination, temperature is normal, blood pressure is 136/84 mm Hg, pulse rat ‘0/min, and respiration rate is 16/min. Jugular venous distention is present. Crackles are noted at the bases of both lungs. A loud $3 is heard at the apex. A grade 2/6 holosystolic murmur is. heard at the left lower sternal border and increases in intensity during inspiration. Abdominal ascites and bilateral pitting edema to the knees are present. Laboratory studies reveal a serum ferritin level of 180 ng/mL. (180 ug/L) and a B-type: natriuretic peptide level of 560 pgiml. (560 ng/L). Serum protein electrophoresis and urine protein electrophoresis are unremarkable. Right heart catheterization demonstrates diastolic equalization of pressures at 18 mm Hg ‘Simultaneous right and left ventricular hemodynamics demonstrate concordant rise and fall of systolic pressures with respiration. Cardiac magnetic resonance imaging with intravenous gadolinium contrast shows a pericardial thickness of 2 mm without enhancement and marked late gadolinium enhancement of the papillary muscle. Echocardiogram shows symmetric left ventricular wall thickness of 11 mm, normal left ventricular cavity size, a left ventricular ejection fraction of 55%, and severe biatrial dilatation. Right ventricular size and function are normal. ‘Tricuspid regurgitation is noted, and the right ventricular systolic pressure is estimated at 72 mm Hg. There is no pericardial effusion. Which of the following is the most likely diagnosis? A. Primary restrictive cardiomyopathy Qo B. Fabry disease ©. Homochromatosis D. Constrictive pericarditis, Question 72 of 100 ‘AT4 years old gentleman with IPF had a echocardiogram showing pulmonary hypertension of 40 mmHg. What is your next step in management? A. Add sildinafl B. Start ilioprost . Start macitantan D. No treatment QeQuestion 73 of 100 61-year-old woman comes to ER because of exertional dyspnea. Her medical background Includes COPD, HFrEF, rheumatoid arthritis. She was hospitalized 3 wooks ago because of pneumonia and received antibiotics, Hor dyspnea progressed despite taking extra doses of furosemide without significant relief. Her BP is 155/90, HR is 77/min and RR is 20/min, Oxygen saturation is 95% on RA. She has mild respiratory distress, lung examination reveals decreased breath sounds on the right with dullness to percussion up to mid zone. Further work up showed evidence of moderate right sided pleural effusion on CXR. Labs: Creatinine: 123 mmolil (61.9-110 pmol/L) Total protein, serum: 7.2 gid (6.0-7.8 gic) Albumin, serum: 3.8 gidL (3.5-5.5 gidL) LDH, serum: 95 mg/Al. (60-100 mg/aL) ‘Thoracentesis is performed on the right and 600 ml of fluid is removed. Pleural fluid analysis are as follows: Leukocyte: 500 (Lymphocyte: 60%) LDH: 60 UiL. Total protein: 3.2 g/dl. Albumin: 1.8 g/dl. Which of the following is the most likely cause of her pleural effusion? ‘A. Rheumatoid pleurisy B. Congestive hear failure Qo . Para-pneumonic effusion D. Malignant pleural effusionQuestion 74 of 100 A 25-year-old man with decompensated liver cirrhosis due to hepatitis B presented to the ‘emergency department with massive hematemesis and molena, This is his third episode of variceal bleeding within the last 2 weeks. His last emergency EGD performed 3 days ago showed grade Ill esophageal varices and he underwent endoscopic variceal ligation. During his current admission to the emergency department, he was resuscitated successfully. His BP is 110/80 and Hb is 8 g/dL, total bilirubin 40 ug/dL., creatinine 100 ugidL., INR 1.4. What isthe best treatment option? [A Discharge the patient and perform endoscopy after 2 weeks as an outpatient B. Endoscopy within 24 hours and band ligation ©. Refer for transjugular intrahepatic portosystemic shunt (TIPS) e D. Esophageal tamponade with Sengsiaken tube E. Hemospray56-year-old man is evaluated during a follow-up visit for diabetic nephropathy. He has a 15- year history of type 2 diabetes mellitus. Medications are insulin detemir, insulin aspart, lisinopril, furosemide, and atorvastatin, ‘On physical examination, blood pressure is 129/76 mm Hg; other vital signs are normal. The remainder of the examination is unremarkable. Which of the following is the A. Caleitrio! B. Aluminum hydroxide ©. Cinacalcet D. Sevelamer Serum ES value ference Ronee Glcium 9.5 mefal (2.4 mmol/)) 9-10.5 mefAl (2.2-2.6 mols!) a 2amgjal23rman 2.045 mg (087-145 mma PTH 385 pg/ml (385 ng/) 10-65 pg/ml (10-65 ng/l) Vitamin 22 elm mai) 31-80 maf! (77-200 moi) corr 25 nio.72m° Sra tka 90 most appropriate treatment?Question 76 of 100 A 32-year-old woman with long-standing diagnosis of systemic lupus erythematosus is evaluated by her rheumatologist as routine follow-up. A new cardiac murmur is heard, and an echocardiogram is ordered. She is feeling well and has no fevers, weight loss, or preexisting cardiac disease. A vegetation on the mitral valve is demonstrated. Which of the following statements is true? A. Blood cultures are unlikely to be positive. Qo B. Glucocorticoid therapy has been proven to ke condition 1d to improvement in this ©. Pericarditis is frequently present concomitantly D. The lesion has a low risk of embolization E. The patient has been surreptitiously using injection drugs.Question 77 of 100 ‘A 34-year-old man presents to the physician complaining of yellow eyes. For the past week, he has felt ill, with decreased oral intake, low-grade fevers (~100"F), fatigue, nausea, and ‘eccasional vomiting. With the anset of jaundice, he has noticed pain in his right upper quadrant. He currently uses marijuana and ecstasy and has a prior history of injection drug use with cocaine. He has no other past medical history, but he was unable to donate blood for reasons that he cannot recall 4 years previously. His social history is remarkable for working as a velerinary assistant. On sexual history, he reports five male sexual partners over the past 6 months. He does not consistently use condoms. On physical examination, he appears ill and has obvious jaundice with scleral icterus. His liver is 15 cm to percussion, palpable 6 cm below the right costal margin. The edge is smooth and tender to palpation. The spleen is not enlarged. There are no stigmata of chronic liver disease. His AST is 1232 IU/L, ALT is 1560, IUIL, alkaline phosphatase is 394 IU/L, total bilirubin is 13.4 mg/dL, and direct bilirubin is 12.2 mg/dL. His international normalized ratio (INR) is 2.3, and activated partial thromboplastin time {aPTT) is 82 seconds, Hepatitis serologies are sent and reveal the following: Hepatitis A IgM negative Hepatitis A IgG negative Hepatitis B core IgM positive Hepatitis B core IgG negative Hepatitis B surface antigen positive Hepatitis B surface antibody negative Hepatitis B e antigen positive Hepatitis B e antibody negative Hepatitis C antibody positive What is the cause of the patient's current clinical presentation? A. Acute hepatitis A infection B. Acuto hepatitis 8 infection Qe . Acute hepatitis ¢ infection D. Chronic hepatitis B infection E. Drug-induced hepatitis,A28-year-old woman with longstanding mild persistent asthma comes to see you because she just found out that she is pregnant. Her only medications are inhaled beclomethasone twice a ay and albuterol as needed. She typically uses her albuteral less than twice per week. She wants to know what to expect regarding her asthma severity and whether any medication changes should be made at this time Which of the following statements is correct? {A Sho should continue her curtont therapy and follow symptoms. Qe B. She should switch from inhaled albuterol as needed to inhaled tiotropium as needed, . She should switch from inhaled beclomethasone to a inhaled salmeterol. D. There is a greater than 70% chance that her asthma symptoms will become less severe during pregnancy. E. There is a greater than 70% chance that her asthma symptoms will become more severe during pregnancy. A 32 year old male body builder decided to go on a dist consists of raw egg whites in addition to other protein supplement to ensure adequate protein for muscle growth. After few weeks he experience decrease energy and found to be hypoglycemic. Which of the following can explain the patient complain? A. Anabolic steroids use B. Carbohydrate restricted diet ©. Hypertrophic Obstructive Cardiomyopathy D. Biotin Defici ey @ E. Hyperketotic dietQuestion 80 of 100 A 71-year-old male has routine yearly labs drawn by his Primary care physician. His total protein is 9.8 g/dL and albumin is 3.5 g/dl. Because of this high protein/albumin ratio, an SPEP with IFE is ordered and shows an IgG kappa spike of 2.6 gic11. Free kappa/lambda light chain ratio is 35. Bone marrow biopsy reveals 8% plasma cells. His Hb, creatinine, calcium, and skelotal survey are all within normal limit. PET-CT revealed no lytic lesions or plasmacytomas What therapy would you offer? ‘A. Melphalan, Bortezomib, Prednisone B. Observation Qe ©. Lenalidomide, Bortezomib, Dexamethasonen D. Bortezomib and Dexamethasone E. Lenalidamide and DexamethasoneQuestion 81 of 100 A 51-year-old truck driver is referred for evaluation of persistent asymptomatic microhematuria. He has not seen a physician since he was first told about blood in his urine during a Department of Transportation physical examination 9 years ago. At that time, he had a ‘computed tomographic sean of the abdomen and pelvis, cystoscopy with retrograde pyelograms, and urine cytology. He was told last year that his blood glucose level was elevated. He has never smoked and takes no medications other than ibuprofen 400 mg approximately twice monthly for headaches. Examination was unremarkable. Serum creatinine 2.1 mg/dL Fasting blood glucose 130 mg/dL Spot urine micro albumin 1586 me/g Urinalysis: Blood +3 Urinalysis: Protein +3 24-h total protein 21g ESR Normal ANA Negative ANCA (C&P) Negative Hepatitis B & C Negative HIV Negative Renal Bx Pending What is the most likely diagnosis? ‘A. IgA nephropathy B. Chronic interstitial nephritis CC. Minimal change nephropathy D. Diabetic nephropathy E. Membranous nephropathyQuestion 82 of 100 In which patients with HFEF is coronary angiography most appropriate and clearly indicated?” A. A 35-year-old lady with severe mitral stenosis, EF 45%, atrial fibrillation and planned for mitral valve replacement B. A52-year-old patient with EF of 30% diabetes, and angina on walking one @ block ©. A 22-year-old patient with HF, EF of 10%, severely dilated left ventricle. D. A 63-year-old man with prior ST elevation myocardial infarction, scarred left anterior descending artery area on nuclear testing, no reversible ischemia, EF of 30%, but short of breath on exertion 47-year-old woman is evaluated for an incidentally discovered right adrenal mass, (On physical examination, blood pressure is 120/80 mm Hg in both arms and pulse rate is B4/min. The abdomen is non-tender, and there are no palpable masses. The remainder of the examination is unremarkable. Non-contrast CT of the abdomen demonstrates a 3.2-cm well-circumseribed, partially cystic, right adrenal le: ‘suppression test is negative for evidence of cartisol hypersecretion. n with a density of 30 Hounsfield units. A low-dose dexamethasone Which of the following is the mast appropriate next step in management? A. Plasma free metanephrines Qe B. Adrenalectomy ©. No adcitional testing is indicated D. Plasma aldosterone to plasma renin ratioQuestion 84 of 100 A 40-year-old patient with Crohn's disease is in need of biologic therapy with infliximab Pre-infusion testing shows the following labs: ALT: 19 UIL HBs Ab: positive HBs Ag: negative, Hbc total Ab: positive. What is the most appropriate action? A. Check and follow HBV DNA levels, B. No action required Qe ©. Booster vaccination against HBV D. Prophylaxis against reverse seroconversion with entecavir 0.5mg dally ‘Compared with intravenous furosemide therapy, venovenous ultrafiltration in patients decompensated heart failure has been shown to result which of the following outcomes? greater improvement in A. Ninety-day mortality rate B. Rate of re-hospitalizations Qo ©. Dyspnea score D. Preservation of renal function E. Electrolyte disturbancesQuestion 86 of 100 Which one of the following drug-side effects matches is NOT correct? A. Efaviring- nightmares B. Zidovudine- Anemia . Tenofovir-Fanconi syndrome D. Atazanavir- renal impairment E. Lamivudine- hepatitis,Question 87 of 100 49-year-old man with no significant medical history presents to the hospital with a one-day history of fever, severe headache, myalgia, and loose stools that began 10 days after he retumed from India (On examination, his temperature is 38.9 °C. his heart rate is 117 beats per minute, his blood pressure is 102/64 mm Hg, his respiratory rate is 24 breaths per minutes, and his oxygen saturation is 98% on room alt Laboratory finding are as follows: WBC count: 4200 per mm® (4,500 ~ 11,000) Hemoglobin: 11.4 g/dL (13.5 17.5) Platelet count: 110.000 per mm? (150,000 - 350,000) AST: 77 U/L (0 ~ 38) ALT: 85 U/L (0 ~ 38) LDH: 285 U/L (100 - 180) Indirect bilirubin: 0.4 mgfdL. (0.1 - 0.3) His creatinine level is normal. His CSF fluid analysis is within normal limits. One set of thick and thin smears is obtained and is found to be negative for malaria. Blood cultures are pending His Chest radiograph shows a mild diffuse interstitial pattern He is admitted to the hospital and started on empiric ceftriaxone and azithromycin for presumed pneumonia. Twelve hours after admission, he reports worsening shortness of breath, headaches, and malaise. Which one of the following next steps is most appropriate in this patient's care? A. Order serological testing for dengue fever B. Broaden antitctc to piperacilin-azobactam and vancomycin. ©. Repeat thick and thin smears for malaria, Qe D. Add ciprofloxacin for enteric bacterial pathogens.A 32-year-old woman arrives to establish primary care. She is sexually active with a new male partner and reports consistent condom use. Medical history is significant for chlamydia cervicitis § years ago and treatment for syphilis 6 years ago. Her only medication is an oral contraceptive. On physical examination, vital signs and the remainder of the examination are unremarkable. A syphilis enzyme immunoassay is positive; rapid plasma reagin testing is negative. A fluorescent treponemal antibody test is positive. Nucleic acid amplification testing is, ‘combination testing is negative. Which of the following is the most appropriate management? A. No further testing or treatment Qe B. Intramuscular benzathine penicilin, single dose . Repeat serology with Treponema palm particle agglutination assay D. Intramuscular benzathine penicillin, weekly for 3 weeks Question 89 of 100 ‘You are called to see a man who is due for elective right hemicolectomy for a colonic carcinoma. His admission ECG shows atrioventricular dissociation with a ventricular response of 45 bpm. He is totally asymptomatic. Which of the following is the most appropriate piece of advice? A. De nothing and let the operation go ahead as planned tomorrow B. Insert a temporary pacemaker before the operation Qe G. Perform an exercise test before the operation D. Postpone the operation and refer for an outpatient permanent pacemaker E. Start an infusion of isoprenaline an hour before the operationQuestion 90 of 100 A27-year-old man with resection of pineal gland tumor developed persistent hyponatremia, He complains of weakness and mild dizziness. Physical examination reveals a BP of 114/70 mmHg and a pulse rate of 100 beats/min (supine), 100/60 mmHg and a pulse rate of 120 beats/min (standing), respiratory rate of 16/min, and a temperature of 99.1F (37.2 C). Cardiac exam is normal. Lungs are clear to auscultation. There is no peripheral edema. He receives 2.5 L of normal saline daily. Lab studies: Na 122 meq/I K 4.2 meq/| cl 96 meq/l HCO3 27 meq/I BUN 22 mg/dl Creatinine 1.4 mg/dl Glucose 80 mg/dl Total Protein 7.69 g/dl Uric Acid 3.5 mg/dl Urine Osmolality 700 mOsm/kgH20. Urine Na 350 meq/I Urine K 24 meq/I Urine Volume 41/24 hrs Which one of the following is the MOST likely cause of this patient's hyponatremia? ‘A. Pseudohyponatremia B. Cerebral satt wasting QO ©. Late voriting D. Adrenal insufficiency E. Syndrome of inappropriate antidiuresis (SIADH)Question 91 of 100 ‘A 33-year-old woman with no prior medical history presents with new- onset hypertension and thunderclap headache after delivering a healthy baby. The baby was delivered vaginally at full term. Blood pressure pre-pregnancy was 110/70 mm Hg, and the pregnancy proceeded without ‘complications. She is using no medication. Physical examination shows blood pressures. repeatedly >150/100 mm Hg, but otherwise is unremarkable. Laboratory data show normal thyroid-stimulating hormone level, uric acid level, liver function test , platelet count, and urinalysis. The patient's serum creatinine level was normal, Which of the following is the likely cause of postpartum hypertension? A. Gestational hypertension B. Pre-eclampsia ¢. Reversible cerebral vasoconstriction syndrome (RCVS) e D. Pain E. HELLP syndrome ‘60-year-old female with history of chronic pain, hyperthyroidism, and depression presents to the emergency department with confusion, diaphoresis, and fever to 42 °C. She has been taking prochlorperazine for several days due to a gastrointestinal iliness in order to keep down the citalopram she takes for depression. What elements of the physical exam will allow you to differentiate neuroleptic malignant, syndrome from serotonin syndrome? A. Hyperretiexia and myoclonus suggests neuroleptic malignant syndrome: rhea and shivering suggests serotonin syndrome e €. Altered mental status suggests neuroleptic malignant syndrome D. Rigidity and stupor suggests serotonin syndromeQuestion 93 of 100 In which of the following clinical scenarios is infliximab therapy contraindicated? ‘A. A29-year-old woman wit left-sided cols and a personal history of optic = @ neurtis B. A 25-year-old weman with ulcerative pancolitis who is 10 weeks pregnant ©. AG5-year-old woman with active colonic Crohn's disease and a history of breast cancer treated eight years ago. D. A 43-year-old man with active lleocolonic Grohn's disease and recent, Giagnasis of latent tuberculosis, currently on week 12 of isoniazid therapy. Question 94 of 100 An 21-year-old female with a history of Sickle cell disease was admitted to the hospital for an acute pain crises. This is her 6th admission in the past 2 years and she has rec ‘and red blood cell transfusions during each admission. On admission, her Hb=7.2 gid (baseline Hb=8.5 g/d1). Her reticulocyte count was 18%, which is increased from her normal baseline of 8%. Her pain is under better control with a Morphine PCA. On admission, she was given 1 unit of pRBC. Ten days later, she endorses having worsening thigh and back pain. Her urine appears very dark with obvious signs of hematuria. Laboratory workup shows signs of hemolysis (elevated LDH, bilirubin), but interestingly, her hemoglobin has dropped to 4.9 Will and her reticulocyte count is only 1%. Coombs testing is positive. She has a hemoglobin electrophoresis sent for and reveals all HbS. fed narcotics What is the most likely reason for her clinical situation? A. Clerical error in matching the pRAC transfusion B. Parvovirus B19 infection ©. Hyperhemolysis, D. Acute chest syndrome E. Delayed Hemolytic transfusion reaction eQuestion 95 of 100 Which of the following is most important for successful resuscitation of an adult patient with out-of-hospital cardiac arrest? A. Early intubation B. IV Atropine ©. 1V antiarnythmie drugs D. Early direct current (DG) shock defibrillation Qo E. IV epinephrine Question 96 of 100 47-year-old man who has a history of poly substance abuse presents with delirium, Reportedly, he ingested an unknown substance. Physical examination: Mental status Disorioy inled Blood pressuret10/70 Pulse 110 (normal heart rhythm) Respiratory rate, breaths 34; Lung fields Clear and no lower limbs edema Na 138 meq/I K 3.8 meq/| cL 100 megq/I Bicarbonate 14 meq/I 20 mg/dl 1.5 mg/dl 7.43 20 mmHg 85 mmHg What is the pationt’s acid-base status? ‘A. High Anion Gap Metabolic acidosis with respiratory compensation B. Acute respiratory alkalosis with appropriate metabolic compensation . High Anion Gap Metabolic acidosis and respiratory acidosis D. Chronic respiratory alkalosis and metabolic compensation E. High Anion Gap Metabolic acidosis and respiratory alkalosis eQuestion 97 of 100 70-year-old male transferred from nursing home with history of shortness of breath and cough. No information is available other than history of chronic pain. He is febrile, tachycardiac and. hypotensive. Labs are pending. CXRis shown, Lio The patient resuscitated and transferred to critical care area. As part of the work up. Echocardiogram is ordered. What are the changes you would expect on the following hemodynamic reading? AA. Ejection fraction normal or increased, and PCWP decreased. B. Ejection fraction decreased, and PCWP increased . Ejection fraction decreased, and PCWP decreased D. Ejection fraction increased, and PCWP increased.Question 98 of 100 Which of the following statements is true regarding available anti-integrin therapies? A. Vedolizumab is more effective in anti-TNF naive patients compared to Qe patients who are anti-TNF experienced, B. Trials of vedolizumab demonstrated an increased risk of infections compared to placebo ©. Checking for JC virus (JCV) antibody Is recommended prior to prescribing vedolizumab, D. Progressive multi-focal leukoencephalopathy has been reported in patients treated with vedolizumab and natalizumab, Question 99 of 100 A 72-year-old woman, who lives alone, was admitted for weakness, inability to walk, and forgetfulness aver a 2-week periad of time. She cooks her own meals. She is slightly lethargic. Physical examination shows BP 124/74 mmHg; pulse 76/min and no orthostatic hypotension. Lung and heart examination is normal. Labs are: Na 120 mea/l Volume IU/day K 3.6 meq/l Na 20 meq/| cl ‘88 meq/l K 2 meq/i BUN 6 mg/dl Urea nitrogen 246 mg ‘Creatinine 0.5 mg/dl Glucose 90 mg/dl Uric Acid 5.2 me/dl Osmolality 110 mOsm/kg H20 Osmolality 250 mOsm/kg H20 Total Protien 68 g/dl Which one of the following Is the MOST likely cause for her hyponatremia? ‘A. Pssudohyponatremia B. Hyponatremia due to hydrachlorethiazide (HCTZ) ©. Hypertonic hyponatremia D. Hyponatremia due to tea and toast iet e E. Syndrome of inappropriate antidiuresis (SIADH)Question 100 of 100 65-year-old male admitted as case of UTI known to have congestive heart failure and chronic Kidney disease who Is receiving warfarin for atrial fibrilation and is found to have an INR of 11 but no evidence of bleeding. Which one of the following management approaches is most ‘appropriate? ‘A. Hold warfarin and administer 10 mg of vitamin k intravenously B. Continue the warfarin at a 25% lower dose C. Hold warfarin and transfuse 4 units of FFP D. Hold warfarin and administer 2.5 mg of vitamin k by mouth Qo